Cannabis or cannabinoids for the management of chronic noncancer pain

Cannabis use for recreational and medical purposes has grown more acceptable and accessible in recent years. Chronic pain is the most common reason for use among persons who use cannabis for medical purposes. The American College of Physicians has issued best practice advice to inform clinicians of the evidence regarding the beneﬁts and harms of cannabis in the management of chronic noncancer pain. The guidance document also highlights populations at high risk for adverse events and provides advice for counselling patients about cannabis for chronic noncancer pain. The advice is intended for clinicians caring for patients with chronic noncancer pain who have had other evidence-based treatments fail and are considering cannabis or cannabinoids.Best practice advice statements:Clinicians should counsel patients about the beneﬁts and harms of cannabis or cannabinoids when patients are considering whether to start or continue to use cannabis or cannabinoids to manage their chronic noncancer pain.Clinicians should counsel the following subgroups of patients that the harms of cannabis or cannabinoid use for chronic noncancer pain are likely to outweigh the beneﬁts: young adults and adolescents, patients with current or past substance use disorder, patients with serious mental illness, frail patients and those at risk for falling.Clinicians should advise against starting or continuing to use cannabis or cannabinoids to manage chronic noncancer pain in patients who are pregnant or breastfeeding or actively trying to conceive.Clinicians should advise patients against the use of inhaled cannabis to manage chronic noncancer pain. Healthcare providers should consult the full guidance document for a discussion of the rationale behind these best practice advice statements.Discussion points with patients who are considering cannabis to manage chronic noncancer pain:The degree of benefit to ease chronic noncancer pain is small, on average. The effectiveness of cannabis or cannabinoids for pain over years of use is unknown. The potential benefits of cannabis for chronic noncancer pain should be weighed against the known short-term and long-term harms. Most people should try other treatment options before trying cannabis or cannabinoids for the management of chronic noncancer pain.Many of the harms associated with cannabis and cannabinoids are related to the total amount of delta-9-tetrahydrocannabinol (THC) used. Use the lowest amount of THC necessary to achieve a beneficial effect.The average effective daily dose of THC used in clinical studies was about 15–25 mg per day.If cannabis or cannabinoids are used for chronic noncancer pain, start at a low dose and titrate. (The document references several expert-based guidelines that provide titration strategies.)The goal of any treatment for chronic pain is to improve patients’ ability to do the things they want and need to do. Establish and review functional goals at the outset. Stop using cannabis or cannabinoids if it is not helping to improve function or if it is causing adverse effects that outweigh the benefit experienced.Patients should keep a record of their daily cannabis or cannabinoid use, including dose and timing, the effect on their chronic noncancer pain and their ability to do things, and any adverse effects.Do not drive after using cannabis or cannabinoids. Be aware that some workplaces may test for drug use (including cannabis and cannabinoids). Smoking cannabis can affect others through secondhand smoke.Cannabis and cannabinoids can be addictive, even when being used to manage chronic noncancer pain. Some signals that indicate a patient may be developing problems with cannabis or cannabinoid use include the development of tolerance (needing more cannabis to get the same effect); withdrawal (experiencing symptoms such as irritability or insomnia when stopping or reducing cannabis use); or effects on social, professional or mental well-being, such as relationship problems, forgoing activities in favour of using cannabis, failing to fulfill obligations, and continuing to use cannabis even when it is causing physical or psychological problems.Possible long-term harms of cannabis useThe guidance document provides a table summarizing the potential long-term harms of cannabis and cannabinoid use. These include cannabis use disorder, cannabis use withdrawal syndrome, cognitive effects (acute and chronic), mental health effects (e.g., acute psychosis, psychotic spectrum disorders), physical health effects (e.g., cancer), cardiovascular effects (e.g., tachycardia, hypertension), gastrointestinal effects (e.g., cannabinoid hyperemesis syndrome) and pulmonary effects (bronchitis; unclear association with lung cancer and chronic obstructive pulmonary disease). Reference:Kansagara D, Hill KP, Yost J, et al; Population Health and Medical Science Committee of the American College of Physicians. Cannabis or cannabinoids for the management of chronic noncancer pain: best practice advice from the American College of Physicians. Ann Intern Med 2025; published online April 4, 2025. (accessed April 17, 2025).

Cannabis or cannabinoids for the management of chronic noncancer pain

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